Some special-needs patients are so scared of being at the dentist’s office, it’s almost impossible to diagnose them.
“Sometimes the lights set them off, sometimes the sounds, they get scared and move around so much, we can’t get a clear idea of even what they need. We can’t get X-rays,” Terry Jones, a dentist in Sacramento, said. “With these behavioral disorders, in some cases you can triage and get that information, but in some cases you just can’t.”
That’s just the dental exam, Jones said. Doing actual dental work can be impossible.
So some of these special-needs patients — including many children with autism or developmental disabilities — must undergo general anesthesia for dental care, and that’s a complicated process.
“These patients are at risk for severe dental problems,” in part because they go to the dentist so rarely, he said. “This is a crisis in care.”
Jones is chair of the Sacramento County Medi-Cal Dental Advisory Committee and a trustee for the California Dental Association.
Special Needs, Special Settings
Fewer facilities across the state want to deliver dental care to special needs patients, largely because of concerns about reimbursement.
In June, Sutter Health Sacramento announced it would no longer offer dental surgery facilities for Medi-Cal patients, as of July 2014. About half of Sutter’s 1,100 general anesthesia dental clients last year were Medi-Cal patients, according to state officials.
Sutter had taken on the bulk of hospital-based special-needs dental patients in the area. Medi-Cal reimbursement didn’t come close to paying for the cost, let alone allow any profit, and Sutter could “no longer go it alone,” according to Holly Harper, the regional community benefits manager for Sutter Health Sacramento.
“We can’t continue to bear the burden of paying for this oral health alone,” Harper said. “This is a service that’s financially unsustainable. It’s time for substantial change. … We’ve continued these services for as long as we can.”
Sutter Sacramento initially agreed to extend those services beyond July, till the end of September. However, because of progress made in a special Senate workgroup convened by state Sen. Darrell Steinberg (D-Sacramento), Harper said Sutter decided to delay discontinuation of Medi-Cal dental surgery services till the end of the year.
According to a recent Sutter email to stakeholders, the end of 2014 may be the end of the line.
“[Sutter Medical Center Sacramento] will stop providing dental services if there is not significant change in Medi-Cal reimbursement in 2015,” the memo said. “Until then, adequate progress has been made for SMCS to extend services temporarily through the end of this year.”
Harper said the workgroup has helped define alternative settings for care if Sutter fully discontinues the services — including other hospitals, nearby federally qualified health centers, ambulatory surgery centers, and dentists and dental offices for some procedures.
State Looking Into Reimbursement Issue
“We are currently assessing the rates for general anesthesia for dental services,” said Anthony Cava, public affairs officer at the Department of Health Care Services, in a written response.
As for when the department might make its decision, Cava could not set a timetable.
“This is a complex issue,” Cava wrote. “We will continue assessing potential solutions on an ongoing basis. Each of the solutions we identify will have its own unique timeline.”
In 2013 statewide, Cava said, there were 23,599 Medi-Cal patients who received dental services and general anesthesia in a hospital setting. DHCS did not give a cost estimate on raising reimbursement rates for that many patients.
DHCS Director Addresses Assembly Legislators
DHCS Director Toby Douglas, testifying at an Assembly Committee on Health hearing in mid-September, said the department will make sure — one way or another — that these patients get care.
“It is our responsibility to make sure people have access to services,” Douglas said.
Rates are part of the equation in this problem, he said — but not the sole answer.
“Access is multidimensional, and we have to look at all different areas,” Douglas said. “Rate is one component, the others are the protocols,” he said, such as clarifying the responsibilities of the health plans and defining what other treatment settings might work for some of these patients.
Douglas added that the department doesn’t have the authority to alter rates whenever it wants to.
“Changing rates is not something we can just do unilaterally,” Douglas said. “That’s not how the process works.”
A change in rates would not require a state plan amendment or federal waiver, state officials said. However, it would require approval from the Brown administration and possibly the Legislature as well, Douglas said.
At the September hearing, Assembly member and committee chair Richard Pan (D-Sacramento) said DHCS officials were informed of this particular problem in Sacramento 18 months ago.
“We have come to a crisis point,” Pan said. “This was brought up a year-and-a-half ago, this is not something that just popped up. We cannot sit here and say we didn’t know this was coming. If there’s something the Legislature needs to do, we need the department to step up and ask. The one option I’m not going to accept is that we don’t have a solution. We’ve had time to work on it. That can’t happen.”
Pan pressed Douglas to find a solution — quickly.
“Can you give me your assurance that people who have disabilities will still receive these services?” Pan asked.
Douglas said the department is required by law to provide access, but Pan continued to ask for his personal assurance.
“That will be assured, yes,” Douglas said.
Sacramento Area Crisis Focuses Statewide Issue
In an area like Sacramento, where just a few hospitals take on these special-needs patients for general-anesthetic dental care, the actions of one or two hospitals can have a significant impact, Jones said.
“It becomes a chain of further and further lack of access to care,” Jones said.
Really, he said, the rates need to come up across the board for dental care, or the state’s access problem will worsen.
“There will be a drop in care, there will be more pain. There will be more infection. There will be more kids going to the emergency room. They will have more medical problems associated with dental problems,” Jones said. “The lack of access is pretty dramatic.”